Candidate and Career Development Plan. J. Michael McWilliams, MD, PhD is an Assistant Professor of Health Care Policy at Harvard Medical School with multidisciplinary training in internal medicine, health policy, and research methods and a strong commitment to health services research on aging adults with chronic conditions. His previous research assessing the effects of Medicare coverage on health care and health outcomes for aging uninsured adults has been nationally recognized, and his future research will focus on improving systems of care for elderly adults in the Medicare program. His career development plans are integrated into his proposed research, include structured training sessions and apprenticeships with senior faculty, and feature a comprehensive curriculum in aging research and Harvard's Clinical and Translational Sciences Center, the Harvard Catalyst. These training activities, in concert with his research, will deepen his understanding of health economics, health care organizations, statistics, and the clinical and social aspects of aging, foster productive collaborations, and support his transition to independence as an innovative investigator who combines multiple disciplines to produce research with important implications for national health policy and the health of elderly Americans. Institutional Environment. The Department of Health Care Policy at Harvard Medical School offers a rich environment for Dr. McWilliams to pursue his research endeavors and develop his career. The Department has a long and successful track record of developing the careers of its junior faculty. He will be supported by the excellent mentorship of Dr. John Ayanian and Dr. Thomas McGuire and by ample computational resources. He will draw from the broad range of disciplines of his mentors and senior collaborators, which include economics, public policy, clinical medicine and gerontology, clinical research in aging, statistics, and business. The larger Harvard community and his advisory committee will foster new collaborations and directions for future research, as well as provide additional training resources through the Catalyst and aging-related seminars. Research Project: Reforming Medicare: Beneficiary Choice, Plan Payment, and Accountable Care. With the population aging, burden of chronic disease rising, and health-care costs growing at an unsustainable rate, the Medicare program faces an enormous challenge: to improve health outcomes while slowing medical spending for a growing population of elderly adults with chronic conditions. In Medicare Advantage (MA), beneficiaries face complex choices among managed care plans, and inadequate risk-adjustment of plan payments has led to perverse incentives to select healthier beneficiaries rather than focus on effective chronic disease care. In addition to this welfare loss and wasteful competition in MA, the delivery system in Traditional Medicare (TM) is fragmented, as fee-for-service payment has provided little incentive for providers to coordinate care or adopt innovative methods of care management. Successful reform of the Medicare program will likely require coordinated efforts to redesign the delivery and payment systems and restructure markets to support informed choices by patients and healthy competition among providers and plans. Therefore, the proposed research project will use national claims and survey data on patients and providers to inform the development of policies to improve systems of care for elderly Americans and achieve greater value in Medicare. First, beneficiary enrollment decisions will be examined to determine if overly complex choices lead to the selection of inferior options, particularly among cognitively impaired adults. Second, the project will evaluate recently improved methods of risk-adjustment to determine if MA plans have responded by reducing counterproductive selection behaviors and increasing their enrollment and retention of patients with chronic illnesses. Third, the project will measure the structural readiness of local delivery systems to form integrated Accountable Care Organizations (ACOs), assess the heterogeneity in this readiness across the country, and examine how integration among physician practices relates to fragmentation of care, quality of care, and health care spending for elderly adults in the Medicare program. This proposed health services research will have important implications for the clinical care of aging Americans. Analyses from Aims 1 and 2 will determine if policies to expand MA as currently structured are likely to increase value in Medicare, or if more fundamental reforms to guide aging beneficiaries through complex choices and refine the payment formula are needed to promote informed decisions and efficient competition. Findings from Aim 3 will characterize the heterogeneity in structural readiness of the delivery system to form integrated ACOs, the corresponding need to match different stages of readiness with different incentives to improve the delivery and payment systems in tandem, and the potential for greater value in Medicare through novel payments to integrated delivery systems. PUBLIC HEALTH RELEVANCE: This proposed research has the potential to influence the development of national health policy and advanced systems of care for the Medicare population, and could thus have a substantial impact on the clinical outcomes of many elderly Americans. The Beeson Career Development Award would greatly enhance Dr. McWilliams'ability to achieve the short-term training and research objectives he has proposed as well as his long-term career goal of making lasting contributions as a national leader in aging research.